Understanding Spinal Stenosis - Essay Example

Understanding Spinal Stenosis Introduction R.D., 87 years old, female, was admitted to the health facility primarily due to onset of “jerky movements” in her upper extremities, occurring only brief and intermittent in the past three months. Further assessment revealed acute dyspnea after a physical activity, and headache and lightheadedness especially when the patient is in the recumbent position. A decrease in exercise tolerance to ten steps from twenty-five in November last year was also noted. No chest pain, paroxysmal nocturnal dyspnea, edema, or leg pain reported. ECG findings do not correlate an abnormal cardiac condition. As in this case, initial clinical presentations of some patients are often complicated with several individual factors such as age and physical activity. In fact, signs and symptoms as headache and dyspnea can be extremely subjective and may significantly vary with each patient judgment. Furthermore, some conditions do not immediately present to instantly warrant a thorough investigation, only manifesting when much damage has already occurred to be clinically evident. Possible aggravation of a previously known condition also contributes to the complexity of the case. As such, arriving at a logical and rational medical diagnosis may at times be challenged with the inconsistencies of observed and reported manifestations by the patient compared with the results of diagnostic and laboratory procedures performed. Even so, appropriate education remains to be one of the most important roles of the nurse in meeting this patient’s physical and psychological needs and prepare her for the foreseen battery of tests necessary to confirm or refute a diagnosis. Maintaining physiological integrity through dependent and independent nursing interventions is necessary for a comprehensive patient care. Besides that, it is also imperative to maintain being an advocate so that the patient is not subjected to unnecessary danger during the performance of these tests (Best, 2002). Pathophysiology Although the patient’s manifestations strongly suggest an underlying heart condition, laboratory and diagnostic studies reveal otherwise. Radiographic results indicate dextroscoliosis and degenerative disc disease of the thoracic spine, degenerative bilateral arthritis of acromioclavicular joints, degenerative arthritis of the left glenohumeral joint, a normal heart size, and focal arteriosclerosis of the thoracic aorta. The constellation of these findings along with breathing problems implies a progression of a previously undiagnosed restrictive lung disease or a neuromuscular condition. Differential diagnosis should include an acute coronary syndrome and other cardiac condition. Direct causes of degenerative bone and joint diseases remain unknown, although metabolic, nutritional, and a history physical injury may contribute to the subsequent alteration of the connective tissues (Smeltzer & Bare, 2006). Degenerative diseases of the joints directly or indirectly affecting the neuro-musculoskeletal component of breathing can be very complicated because it can mimic several other pathologies. For instance, dextroscoliosis prevents optimum lung expansion, thus causing decreased oxygenation of the blood in the pulmonary circuit. Furthermore, damage to the intervertebral discs may impinge nerves crossing the tracts and can cause spasmic movements of the affected limbs. In some cases, motor nerves that supply the muscles of breathing may also be affected and can cause dyspnea. Moreover, arthritis of the acromioclavicular and glenohumeral joints can cause localized pain especially upon increased joint movement as in labored breathing, and thus may limit adequate lung expansion (Ignatavicius & Workman, 2006). Systemic consequences of inadequate oxygenation at the pulmonary level due to neuro-musculoskeletal causes can have tremendous effect even with minor physical activity like talking and ambulation. On the other hand, ACS and other cardiac condition usually manifest bold physical examination findings that correlate well with laboratory and other diagnostic procedures. History Patient has a past medical history of Heart Failure with Preserved Ejection Fraction (HFPEF), diagnosed in 2010 with an ejection fraction of 60% and a right ventricular systolic pressure of 40 mmHg during that time. She is also suspected to have hypertension, and diabetes mellitus as suggested by an HgbA1C of 8%. In addition, she was diagnosed of having meningioma in 2009 also presenting as an acute or chronic dyspnea, by which she already had undergone resection. She regularly consults PCP. Nursing Physical Assessment Upon admission, the patient had the following vital signs: Temperature- 36.5 C, Pulse Rate- 77, Respiratory Rate- 18, Blood Pressure- 140/65 mmHg, and Oxygen Saturation of 98%. The head was atraumatic and normocephalic. Conjunctivae were normal and sclerae were anicteric. Examination of the neck revealed no jugular vein distension. No lymphadenopathy noted. While there is a normal chest excursion and no crackles were heard upon auscultation of the lung fields, the use of accessory muscles of breathing while talking was noted. Auscultation of the heart reveals no murmur, gallop, or rub. Normoactive bowel sounds were heard upon auscultation of the abdominal area. No hepatosplenomegaly noted. No edema and cyanosis seen on the lower extremities. Pulses were graded 2+ bilaterally on the radial and dorsalis pedis. The patient was oriented to time, place, and person. Cranial nerve functions were intact. Related Treatments Except for the Acetaminophen 300mg/ Codeine 30 mg prescribed for headache, no specific treatments were prescribed yet until test results are available. Laboratory procedures ordered include hematology and blood chemistry. Other diagnostic procedures include chest X-ray PAL view, ECG, echocardiography, MRI of the head, and pulmonary function tests with MIP, MEP, and SNIF. Nursing Care Plan Nursing Diagnosis Ineffective breathing pattern related to musculoskeletal impairment as evidenced by use of accessory muscles of breathing even in minor physical activity secondary to dextroscoliosis and degenerative disc disease of the thoracic spine Patient Goal Patient will be able to understand the importance of complying with the tests prescribed for her condition to ensure correct diagnosis and management. Nursing Interventions Assess and monitor vital signs as necessary to determine progression of the condition. Educate on the importance of undergoing the prescribed several diagnostic procedures to ensure correct management (Smeltzer & Bare, 2006). Monitor for signs of worsening of condition. Encourage verbalization of feelings regarding current health status. Evaluation After a teaching- learning session, patient showed positive behaviors indicating adequate understanding of her need to comply with the management of her condition. Recommendations Involve the patient’s son in case management to promote compliance. Keep weight within normal as obesity can aggravate dyspnea (Ignatavicius & Workman, 2006). References Best, Janie T. (2002). Understanding Spinal Stenosis. Orthopaedic Nursing, 21 (3): 48-56. Ignatavicius, D., & Workman, M. (2006). Medical-surgical nursing: Critical thinking for collaborative care (5th ed.). Philadelphia: W.B. Saunders. Smeltzer, S.C. & Bare, B.G. (2006). Brunner and Suddarth's textbook of medical-surgical nursing (10th ed). Philadelphia, PA: Lippincott Williams & Wilkins. Read More